1,083 diversions’ reported in last 5 years in Colorado

Anesthesiologist Sherry Gorman describes the trust in an operating room as absolute. That’s why she and other physicians assumed their syringes were safe – until a drug-addicted surgery technician stole their painkilling drugs, injected herself and replaced the missing medication with saline.

Gorman and other doctors were accused of unknowingly injecting patients with the bogus narcotics that killed no pain. Worse, they were contaminated with the technician’s hepatitis C as well.

“I do feel awful,” Gorman said. “I hope that every patient that’s impacted by this ends up coming through OK and ends up being cured of the virus and living a long and fulfilling life.”

Gorman was one of the physicians at Rose Medical Center in Denver who settled negligence lawsuits. About 6,000 patients at two hospitals – Rose and Audubon Surgery Center in Colorado Springs – had to be tested for hep C, and three dozen turned out to be infected. Many had to undergo difficult treatments for a year or more.

This case in 2008-09 was rare – not because drugs were stolen from a hospital, but because the surgery tech, Kristen Parker, was prosecuted and sentenced to 30 years in prison.

Colorado Public News found that drug diversion, by health-care professionals and by people outside the system, is a serious issue in the state. Health facilities reported to the state health department 1,083 cases of missing drugs in the last five years. Of that total, 309 instances were reported by hospitals.

In the last three years, only one case turned up in Southwest Colorado in a search of online public records kept by the Colorado Department of Public Health and Environment. In March 2011, a Mercy Regional Medical Center nurse took four doses of oxycodone and resigned after admitting the transgression.

No one seems to track whether thefts are investigated and prosecuted. Jeff Dorschner, spokesman for the U.S. Attorney’s Office in Denver, which prosecutes some of such cases, could remember only three hospitals where staff-member theft made it to court in recent years.

Helen Kaupang, who heads the drug diversion section of the federal Drug Enforcement Administration in Denver, declined to provide any information about how many drug diversion cases her office has investigated or taken to prosecution. She told Colorado Public News – incorrectly – that hospitals are not required to report drug diversions to the DEA.

In fact, hospitals must report drug losses to her office within one day, on DEA Form 106, according to the Colorado Hospital Association.

The state health department investigated its 1,083 reports to ensure that each facility has procedures to prevent loss or theft from recurring, said spokesman Mark Salley. But it’s not the health department’s job to track whether criminal cases are pursued by law enforcement, he said.

In the incident at Rose, Parker had started working at the medical center in late 2008 and by her second day had figured out how to steal syringes of fentanyl, a narcotic pain killer used for anesthesia during surgery, from the operating room.

The hospital had a password-controlled system for dispensing narcotics in the operating room.

“I had every drug drawn up and prepared before the patient entered the room,” Gorman said. “I would take my drugs and put them in one of the drawers of the anesthesia cart. I would hide them under various pieces of equipment.”

Other doctors kept their narcotics-filled syringes in fanny packs, “and some left them out and ready to go with a towel laid over them,” Gorman said.

She doesn’t remember ever seeing Parker. “I can’t imagine what would have gone through her mind that would have made her inflict such a devastating consequence on anybody, especially these helpless people who came in for care,” Gorman said.

Parker was caught in an operating room where she didn’t belong and fired. Within 12 days, she had a new job at Audubon Surgery Center in Colorado Springs, where she contaminated more patients.

When police asked Parker what advice she had for doctors such as Gorman to keep them from falling prey to junkies such as her, she told them, “Be more aware of what you leave lying around.”

John Burke, president of the National Association of Drug Diversion Investigators, found Gorman’s statements naive. “This drug problem is nothing new,” he said.

When he worked in drug enforcement in Cincinnati, he said, his team arrested a staff member a week for drug theft, and he can’t believe that city’s experience was unusual. He said the case rate was high because they actively enforced the law, warning hospital administrators they could go to prison for failure to report.

For the patients, the Parker case was like Russian roulette. Lauren Lollini had kidney stones removed and ended up with hepatitis C. She has cleared the virus out of her system but still wonders if her liver was damaged. “Is my immune system compromised?”

Follow-up

All the hospitals and anesthesiologists who were sued in the Parker case settled out of court. Gorman is still practicing, including at Rose. She wrote a fictional account based on her experience at Rose under the pseudonym Kate O’Reilly and titled the novel It’s Nothing Personal.

Rose has since changed its medication security policies, and doctors now must have their fingerprints scanned to get their narcotics.

Boulder Community Hospital had a similar case in 2008, in which Ashton Paul Daigle, a surgical nurse, injected himself and returned the syringes for use on patients. He did not have a disease such as hep C or AIDS, which could have been passed on, and was sentenced to four years in prison. Boulder Community Hospital has added video and software monitoring of the machines that dispense narcotics and no longer allows vials to be returned and given to another patient.

Two employees of St. Anthony Central were arrested for stealing drugs in 2009, but there were no reports of contamination.

After the Rose case, the Colorado Hospital Association convened a task force to recommend new procedures. It supported legislation, which was passed into law, requiring surgical technicians to be registered with the state. Another new law allows hospitals to tell other hospitals if a former employee put their patients at risk.

Colorado Public News, a nonprofit news organization, reports on issues of statewide interest. It partners with Colorado Public Television 12, Denver’s independent PBS station.